Early health problems predict lower educational attainment, but it remains unclear whether this is due to health problems weakening school performance or due to other mechanisms operating above and beyond school performance. We employed counterfactual-based mediation analysis on a register-based sample of Finnish adolescents born in 1988-1993 (n = 73,072) to longitudinally assess the direct (unexplained byschool performance, as measured by grade point average) and indirect (pure mediation and mediated interaction via school performance) effects of early adolescent somatic and mental health problems on the noncompletion of upper secondary education and track choice (vocational vs. general). Mental disorders were associated with the largest increases in both noncompletion and choosing the vocational track, but somatic conditions also showed small but robust associations. Weakened school performance mediated up to one-third of the differences in noncompletion and around half of the differences in track choice. When the same analyses were conducted within sibships, the total effects of health problems on educational pathways were weaker, but the contribution of school performance remained similar. In counterfactual simulations that assigned everyone an above-median school performance-that is, eradicating below-median school performance-about 20-40 percent of the effects of mental disorders on educational pathways remained. Our results suggest that while impaired school performance is an important component in health-related selection to education, it does not fully explain the shorter and less academically oriented educational careers of adolescents with health problems. These adolescents may benefit from additional educational support regardless of their formal school performance.

Workplace downsizing and closure have been considered natural experiments that strengthen causal inference when assessing the association between unemployment and health. Selection into unemployment plays a lesser role among those exposed to severe workplace downsizing. This study compared mortality for individuals unemployed from stable, downsized, and closed workplaces with a reference group unexposed to unemployment. We examined nationally representative register data of residents of Finland aged 25-63 years in 1990-2009 (n = 275,738). Compared with the control group, the hazard ratio for substance use-related mortality among men unemployed from stable workplaces was 2.43 (95% confidence interval (CI): 2.22, 2.67), from downsized workplaces 1.85 (CI: 1.65, 2.08), and from closed workplaces 2.16 (CI: 1.84, 2.53). Among women, the corresponding estimates were 3.01 (CI: 2.42, 3.74), 2.39 (CI: 1.75, 3.27), and 1.47 (CI: 1.09, 1.99). Unemployment from stable workplaces was associated with mortality from psychiatric and self-harm-related conditions. However, mortality due to ischemic heart disease and other somatic diseases decreased for those unemployed following closure. The results indicate that selection mechanisms partially explain the excess mortality among the unemployed. However, substance-use outcomes among men and women, and fatal accidents and violence among men, might be causally associated with unemployment.

Background: Life course epidemiology suggests that early life circumstances affect adult mortality, but most of the evidence is based on cohorts born in the beginning of the 20th century. It remains unclear whether and how the influences of early life circumstances on mortality have changed in later birth cohorts.

Methods: Analyses rely on 10% register-based samples of households drawn from the 1950 and the 1975 Finnish censuses, with consistent follow-up of socioeconomic and housing-related characteristics and early mid-life mortality (at ages 30–55 years). We estimate survival models for the associations between childhood circumstances and all-cause, internal and external mortality for cohorts born in 1936–50 and 1961–75 adjusting for attained social characteristics. We estimate sibling intraclass correlations as summary measures of all early life and familial influences.

Results: Adverse childhood social circumstances were typically associated with about 10–30% excess cause-specific mortality. These associations were almost fully attenuated by adjustment for achieved later life social characteristics. Early life influences have grown over time for mortality from external causes, particularly as related to home ownership and family type. Differentials have remained stable for internal causes. The intraclass correlations further confirmed the increasing association of early life circumstances on external-cause mortality.

Conclusions: Our analyses show that the associations between childhood characteristics and mid-life mortality are substantial and almost fully mediated by achieved adult social characteristics. The increase in the contribution of childhood circumstances to mid-life mortality is driven by ever stronger associations with external causes of death.

Background Adolescent health problems are more prevalent in families with low socioeconomic position, but few studies have assessed the role of parental health in this association. This study examines the extent to which parental health problems, particularly those related to high-risk health behaviour, might explain the association between parental education and adolescent health problems due to violence, self-harm and substance use.

Methods We used longitudinal register data on a 20% representative sample of all families with children aged 0-14 years in 2000 in Finland with information on parental social background and parental and offspring health problems based on hospital discharge data. We estimated discrete-time survival models with the Karlson-Holm-Breen method on hospital admissions due to violence, self-harm and substance use among adolescents aged 13-19 years in 2001-2011 (n=145 404).

Results Hospital admissions were 2-3 times more common among offspring of basic educated parents than tertiary educated parents. Similar excess risks were observed among those with parental mental health problems and parental health problems due to violence, self-harm and substance use. The OR for offspring of basic educated parents was attenuated from OR 2.73 (95% CI 2.34 to 3.18) to OR 2.38 (2.04 to2.77) with adjustment for parental health problems, particularly those due to violence, self-harm and substance use. Having both low parental education and parental health problems showed simple cumulative effects.

Conclusions The excess risks of hospital admissions due to violence, self-harm and substance use among adolescents with lower educated parents are largely independent of severe parental health problems.

Marriage is associated with better mental health. While research on the mental health of cohabiting individuals has increased in recent years, it has yielded mixed results thus far. We assessed whether the mental health of cohabiters is comparable to that of married individuals or those living alone using longitudinal data on psychotropic medication purchases. Panel data from an 11% random sample of the population residing in Finland for the years 1995 to 2007, with annual measurements of all covariates, were used. Ordinary least squares (OLS) models were applied to disentangle the relation between cohabitation and psychotropic medication purchases while controlling for relevant time-varying factors (age, education, economic activity, and number of children), and individual fixed effects (FE) models to further account for unobserved time-invariant individual factors. Our sample consisted of 63,077 men and 61,101 women aged 25 to 39 years in 1995. Descriptive results and the OLS model indicated that the likelihood of purchasing psychotropic medication was lowest for married individuals, higher for cohabiters, and highest for individuals living alone. This difference between cohabiting and married individuals disappeared after controlling for time-varying covariates (percent difference [% diff] for men: 0.3, 95% confidence interval [CI]: -0.0, 0.6; % diff for women: -0.2, 95% CI: -0.6, 0.2). Further controlling for unobserved confounders in the FE models did not change this non-significant difference between cohabiting and married individuals. The excess purchases of psychotropic medication among individuals living alone compared to those cohabiting decreased to 1.2 (95% CI: 1.0, 1.4) and 1.4 (95% CI: 1.1, 1.6) percentage-points in the fully-adjusted FE model for men and women, respectively. Similar results were found for all subcategories of psychotropic medication. In summary, these findings suggested that the mental health difference between cohabiting and married individuals, but not the difference between cohabiting individuals and those living alone, was largely due to selection.

Parental unemployment is associated with worse adolescent mental health, but prior evidence has primarily been based on cross-sectional studies subject to reverse causality and confounding. We assessed the association between parental unemployment and changes in adolescent psychotropic medication purchases, with longitudinal individual-level fixed-effects models that controlled for time-invariant confounding. We used data from a large, register-based panel of Finnish adolescents aged 13-20 years in 1987-2012 (n = 138,644) that included annual measurements of mothers' and fathers' employment and offspring psychotropic medication purchases. We assessed changes in the probability of adolescent psychotropic medication purchases in the years before, during, and after the first episode of parental unemployment. There was no association between mother's unemployment and offspring psychotropic purchases in the fixed-effects models, suggesting this association is largely driven by unmeasured confounding and selection. By contrast, father's unemployment led to a significant 15%-20% increase in the probability of purchasing psychotropic medication among adolescents even after extensive controls for observed and unobserved confounding. This change takes at least 1 year to emerge, but it is long-lasting; thus, policies are needed that mitigate the harm of father's unemployment on offspring's mental well-being.

Because people tend to marry social equals – and possibly also because partners affect each other’s health – the social position of one partner is associated with the other partner’s health and mortality. Although this link is fairly well established, the underlying mechanisms are not fully identified. Analyzing disease incidence and survival separately may help us to assess when in the course of the disease a partner’s resources are of most significance. This article addresses the importance of partner’s education, income, employment status, and health for incidence and survival in two major causes of death: cancer and cardiovascular diseases (CVD). Based on a sample of Finnish middle-aged and older couples (around 200,000 individuals) we show that a partner’s education is more often connected to incidence than to survival, in particular for CVD. Once ill, any direct effect of partner’s education seems to decline: The survival chances after being hospitalized for cancer or CVD are rather associated with partner’s employment status and/or income level when other individual and partner factors are adjusted for. In addition, a partner’s history of poor health predicted higher CVD incidence and, for women, lower cancer survival. The findings suggest that various partner’s characteristics may have different implications for disease and survival, respectively. A wider focus on social determinants of health at the household level, including partner’s social resources, is needed.

Background Previous studies have found depression to be negatively associated with the prognosis of both cardiovascular disease (CVD) and cancer, but this may partly reflect reverse causality. We limited the possibility of reverse causality by measuring depression before the first diagnosis of CVD or cancer.

Methods We used an 11% longitudinal random sample of the Finnish population aged 25 years or older who are residents of Finland for at least 1year between 1987 and 2007, with an 80% oversample of those who died during this period. Those who had their first incidence of coronary heart disease (CHD) (n=107966), stroke (n=68685) or cancer (n=113754) between 1998 and 2012 were followed up for cause-specific mortality from the date of diagnosis until the end of 2012. Depression was defined as having antidepressant purchases two to three calendar years before the incidence. Logistic and Cox regression models were used to examine short-term and long-term mortality by depression status.

Results Long-term mortality after diagnosis was 1.34 (95% CI 1.25 to 1.44) for CHD, 1.26 (95% CI 1.15 to 1.37) for stroke and 1.10 (95% CI 1.04 to 1.16) for cancer in those who had used antidepressants in two consecutive calendar years as compared with those with no purchases. Short-term mortality from CHD was elevated among persons with depression (OR=1.30; 95%CI 1.06 to 1.61), but no association was found for stroke.

Conclusion Pre-existing depression is associated with a worse prognosis of CHD, stroke and cancer. More attention in the healthcare system is needed for patients with chronic diseases who have a history of depression.

The effects of substance abuse on other family members are not fully established. We estimate the contribution of parental substance abuse on offspring psychiatric morbidity in late adolescence and early adulthood, with emphasis on the timing and persistency of exposure. We used a nationally representative 20% sample of Finnish families with children born in 1986-1996 (n = 136,604) followed up in 1986-2011. We identified parental substance abuse and offspring psychiatric morbidity from hospital discharge records, death records and medication registers. The effects of parental substance abuse at ages 0-4, 5-9 and 10-14 on psychiatric morbidity after age 15 were estimated using population averaged and sibling fixed effects models; the latter controlling for unobserved factors shared by siblings. Parental substance abuse at ages 0-14 was associated with almost 2-fold increase in offspring psychiatric morbidity (HR = 1.86, 95% CI 1.78-1.95). Adjustment for childhood parental education, income, social class and family type reduced these effects by about 50%, with some further attenuation after adjustment for time-varying offspring characteristics. In the sibling fixed effects models those exposed at 0-4 or 5-9 years had 20% (HR = 1.20, 95% CI 0.90-1.60) and 33% (HR = 1.33, 95% CI 1.01-1.74) excess morbidity respectively. Also in sibling models those with early exposure at ages 0-4 combined with repeated exposure in later childhood had about 80-90% higher psychiatric morbidity as compared to never exposed siblings (e.g. for those exposed throughout childhood HR = 1.81, 95% CI 1.01-3.25). Childhood exposure to parental substance abuse is strongly associated with subsequent psychiatric morbidity. Although these effects are to a large extent due to other characteristics shared within the parental home, repeated exposure to parental substance abuse is independently associated with later psychiatric morbidity.

Objectives To quantify how large a part of educational dropout is due to adverse childhood health conditions and to estimate the risk of dropout across various physical and mental health conditions. Study design A registry-based cohort study was conducted on a 20% random sample of Finns born in 1988-1995 (n = 101 284) followed for school dropout at ages 17 and 21. Four broad groups of health conditions (any, somatic, mental, and injury) and 25 specific health conditions were assessed from inpatient and outpatient care records at ages 10-16 years. We estimated the immediate and more persistent risks of dropout due to health conditions and calculated population-attributable fractions to quantify the population impact of childhood health on educational dropout, while accounting for a wide array of sociodemographic confounders and comorbidity. Results Children with any health condition requiring inpatient or outpatient care at ages 10-16 years were more likely to be dropouts at ages 17 years (risk ratio 1.71, 95% CI 1.61-1.81) and 21 years (1.46, 1.37-1.54) following adjustment for individual and family sociodemographic factors. A total of 30% of school dropout was attributable to health conditions at age 17 years and 21% at age 21 years. Mental disorders alone had an attributable fraction of 11% at age 21 years, compared with 5% for both somatic conditions and injuries. Adjusting for the presence of mental disorders reduced the effects of somatic conditions. Conclusions More than one fifth of educational dropout is attributable to childhood health conditions. Early-onset mental disorders emerge as key targets in reducing dropout.